Wouter Leclercq

Preoperative medical record-keeping can be improved: New informed consent form assists both physicians and patients 149 9 NEWSIC STANDARD FORM Based on the obtained practical examples, the literature and the case law, as well as the feedback from the experts and organisations consulted, we drew up a list of data deemed necessary for a SIC form. First of all, the form must establish the hospital, main physician and patient involved. In addition, the 3 domains of the SIC must be specifically named: basic conditions, information and consent (see the Table 9.1). In total, this form records 19 items. In addition, there is the possibility to document additional information (supervisor, witnesses). Figure 9.1 shows an example of the standard form for preoperative informed consent that we have developed using this method. In some of the hospitals involved, the EPF was redesigned (Figure 9.2) to test this form in practice. For the physician, the process is the following. The physician clicks on ‘Surgery’ at the bottom of the outpatient clinic file, which opens a checklist called ‘Informed Consent’; the physician then completes the various items (see Figure 9.2). The hospital information system automatically fills in data about the hospital, the department, the treating physician, the patient and the date on the form. The physician assesses the patient’s competence and can systematically review all the information discussed. After this, the physician is prompted to check whether the patient has actually understood all the information. The file should also contain information about additional sources of information that have been mentioned or provided, such as leaflets, websites or information programmes. Finally, the patient’s consent is recorded. The SIC form is then approved and printed for the patient with the press of a button. The patient will also receive a brief description of the purpose of this form, and is given contact information in case of further questions, providing the patient with a ‘leaflet’ for the surgery.